Ultrasound Diagnostic Services

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. The facilities and equipment met the needs of people, but equipment was not maintained in line with best practice. People were not always protected kept safe.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

During this assessment we did not speak with patients or any family or carers with them.

The service had a positive culture of safety, based on openness and honesty. Staff listened to concerns about safety, however there were limited systems and processes in place to promote incident reporting. This meant opportunities to continually identify and embed good practice, and learn lessons could be missed. Staff working in the service were supported to raise safety concerns through an open and collaborative culture. The registered manager maintained an open-door policy, and staff could escalate concerns if needed. The service did not have a formal whistleblowing policy, staff said they were aware of how to report issues. Following the inspection the service informed us they had introduced a whistleblowing policy/procedure. However, the policy did not document when a review would be due and no evidence was submitted to demonstrate this policy/procedure was shared with staff. Team meetings were ad-hoc and there was limited evidence of formal systems to promote incident and complaint reporting. Therefore, some learning and improvements may be missed. Reception staff routinely verified patient registration details, including email addresses, telephone numbers, and consultant or GP information, at each appointment. This was introduced following an incident where an invoice had been sent to the wrong address. Text reminders for appointments were also sent, but only after contact details were confirmed in order to avoid breaches of sensitive information. However, following the inspection the registered manager informed us that this process was as a result of COVID and not due to an incident. We were informed the patient had not updated their details which was why an invoice was sent to the wrong address.

Safety and accountability were reinforced through regular peer audits. Sonographers and consultants audited each other’s work, with feedback provided during appraisals or one-to-one review meetings. For example, obstetric scans were reviewed against national guidelines, and any discrepancies were promptly addressed to improve practice.

During this assessment we did not speak with patients or any family or carers with them.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The service ensured continuity of care when people moved between different services.

The service had structured care pathways in place to ensure continuity of care. There were effective processes in place to refer patients to other services if needed. The service collaborated with GPs, and in house consultants, maintaining clear communication and documentation. As treatment was provided on an outpatient basis, continuation of people’s care was maintained by the clinician who had referred the person to the service. For those patients who self-referred, the clinic required the patient to provide their GP or consultant’s details, so scan results could be forwarded

Following the scan, the service provided the referring clinician with a detailed report. The patient was also provided with a copy of their images and report for their own records. Treatment decisions were made by the referring clinician. In urgent cases, staff working in the service would contact the referring clinician directly to ensure they were aware of the results, and could take action as needed.

The service had processes in place for urgent medical concerns, such as suspected ectopic pregnancies or significant bleeding. These patients were referred immediately to local Early Pregnancy Units (EPUs) or Emergency Departments (EDs), depending on the severity of the condition. These referrals were made promptly to ensure patient safety and timely intervention.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

During this assessment we did not speak with patients or any family or carers with them.

The service worked with people to understand and manage risks. Staff provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them.

For patients who were referred by their own consultant or GP, the service expected the referring clinician to discuss the risks involved in the scan with the patient. Patients undergoing invasive testing such as tissue sampling were given additional counselling by the service’s practitioner. Following this discussion, they were asked to sign a consent form, prior to any procedure. A copy of this consent form was provided to the patient for their records. This approach ensured patients were fully informed about the potential risks of the procedure and had the support needed to make decisions that were in line with their personal circumstances.

Patients who self-referred for screening and non-invasive pre-natal testing (NIPT) were provided with standard information and leaflets, in line with National Screening Committee (NSC) guidance. This ensured that they were informed about the risks associated with the procedures.

Patient risk assessments were regularly reviewed as part of the service’s commitment to patient safety, while also respecting the autonomy of each patient. Throughout the process, patients were encouraged to actively participate in discussions about their care, ensuring that their preferences and concerns were considered when making decisions about managing risks. This approach balanced both safety and individual choice, empowering women to be involved in decisions related to their care.

The service did not always ensure a safe care environment; equipment was not always maintained in line with best practice. Equipment was not maintained in line with manufacture’s guidance. The two ultrasound machines on loan, had no service contracts in place. The third machine owned by the service was last serviced in October 2023. Following the inspection the service informed us that the ultrasound machines were serviced in March 2025.

The service did not always ensure a safe care environment; equipment was not always maintained in line with best practice.

Equipment was not maintained in line with manufacture’s guidance. The two ultrasound machines on loan, had no service contracts in place. The third machine owned by the service was last serviced in October 2023. We were told service level agreements for the machines were being chased and servicing of all machines had been arranged for March 2025. As this was after our visit, we were unable to confirm this had taken place.

There were no processes in place to log and label faulty equipment. We saw two ultrasound machines awaiting disposal, stored in clinical areas without not for use signage, meaning these could be used. We were told these had not been used for over two years. Certificates to confirm data had been removed to allow the machine to be disposed of had not been provided to the service. Following our site visit evidence to demonstrate all patient data had been removed from these machines was provided. Following the inspection the registered manager informed us the machines had been removed.

There were five transvaginal ultrasound probes in the clinic. We noted a broken transvaginal probe stored in a cupboard was not labelled as broken. meaning it could have been used. Following the inspection the registered manager informed us that the probe was removed. Records of transvaginal probe usage, including decontamination were not maintained, posing a risk of cross infection. Following the inspection the registered manager informed us that documentation of decontamination lot codes had been added to the ultrasound system software and was recorded in individual patient records.

There was a designated fire escape route, however the external fire exit door was fitted with locks. We were told that the door had two locks and each day one lock was unlocked and the keys were then placed in the second lock for staff to access. However during the inspection we did not see keys in the door. This meant that in an emergency it would not be possible to open the door to leave the building.

There was no fire evacuation chair, meaning the evacuation of patients with mobility issues would be delayed. We were told the service had raised the lack of a fire evacuation chair with the building manager, but this matter had not been resolved. Following the inspection the service manager informed us that this was not a requirement for the service. However, no evacuation plan was submitted to demonstrate how the service would support those with mobility issues during an evacuation.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.